Rectal Bleeding

What is Rectal Bleeding?

Rectal bleeding, also known as hematochezia, is a common issue that often goes unreported, but it could indicate a problem in the lower digestive system. It could stem from specific conditions relating to the rectum such as hemorrhoids (swollen blood vessels in the rectum), fissures (small tears in the lining of the anus), proctitis (inflammation of the rectum lining), and anorectal cancer (cancer affecting the anus and/or rectum). However, less than half of those experiencing rectal bleeding actually seek medical help.

The bleeding will present itself as bright red blood coming out from the anus. The severity of the bleeding could range from mild to severe, based on the underlying cause. Mild instances could show up as a streak of red blood in the stool or on toilet paper after wiping. More severe instances could involve a considerable amount of blood. This explanation will focus more on hemorrhoids because they’re usually the most common reason for rectal bleeding in middle-aged and elderly people.

What Causes Rectal Bleeding?

Gastrointestinal bleeding refers to any bleeding that starts in the gastrointestinal tract, which is the part of the body involving the stomach and intestines. We split this type of bleeding into two categories, based on whether it’s starting in the upper part or lower part of this tract. The point we use to decide which category to place the bleeding in is called the ligament of Treitz, a sort of “dividing line” in the digestive system. If you’re experiencing rectal bleeding, the cause is typically found in the lower part of your gastrointestinal tract. This includes parts of your body like your small intestine beyond the duodenum, your colon, rectum, or anal canal.

Colon cancer causes can include bleeding. As the cancer cells grow, they form abnormal blood vessels, which can be quite fragile and bleed, especially as the cancer grows. While colon cancer isn’t the leading cause of rectal bleeding—it only causes about 3.4% of rectal bleeding cases—it’s one of the more important causes we need to rule out, especially in older patients.

Inflammatory bowel disease, which is a condition that causes long-term inflammation in the digestive tract, can also make you bleed rectally. Two examples of this disease are ulcerative colitis and Crohn’s disease. If you have this condition, along with bleeding, you might also have symptoms like diarrhea and abdominal pain.

Many people have diverticular disease, which is when small pouches form in the wall of the colon. These pouches can form at weak points where blood vessels penetrate the muscle layer. The blood vessels within these pouches can become fragile over time and can rupture, causing bleeding.

Hemorrhoids can also cause rectal bleeding. Hemorrhoids are cushion-like structures found under the lining of your anal canal, usually in three specific positions: left lateral, right anterior, and right posterior. They’re made up of blood vessels and muscle fibers, and can start causing problems when the muscle fibers become weak. There are different types of hemorrhoids and several different symptom levels, but internal ones often cause painless bleeding.

Anal fissures, which are tears in the lining of your anal canal, are another possible cause. These fissures are often associated with painful bowel movements and blood-streaked stools and can happen because of constipation, hard stools, or childbirth.

Infections, such as sexually transmitted diseases and specific bacterial infections, can also cause rectal bleeding. And, in some cases, even bleeding that actually starts in your upper gastrointestinal tract can show up as rectal bleeding, especially if it’s a large amount of blood.

In general, when a doctor is trying to figure out what’s causing gastrointestinal bleeding, they’ll also think about other underlying issues that might be contributing. These can include things like a deficiency in vitamin K, blood clotting disorders like hemophilia, a low platelet count, or a reaction to a blood thinner medicine.

Risk Factors and Frequency for Rectal Bleeding

Not many studies offer clear numbers on the occurrence of rectal bleeding in the general population. Nonetheless, research conducted at the community level indicates that between 13% to 34% of people experience this condition. Interestingly, the results on whether rectal bleeding more frequently impacts men or women are inconclusive. According to research by Eslick and team, men and women are roughly equally affected. The study observed higher rates of rectal bleeding in women aged 18 to 39 and over 60, while men experienced more incidences when they were between 40 and 49.

Something of note is that only about 40% of people who have rectal bleeding actually seek medical help. This is mostly because they don’t think the issue is severe enough to warrant medical attention. This group of patients is mainly those who are over 60 years old.

Signs and Symptoms of Rectal Bleeding

In order to determine the possible causes of rectal bleeding, a thorough history and physical examination is necessary. Factors such as the start and end of the bleeding, its frequency and severity, any visible clots, and other symptoms are all crucial to this diagnosis. For instance, brighter blood can point to a different diagnosis than darker, older blood. Pain in the stomach, weight loss, changes in bowel movements, and relevant medical history such as having undergone a surgery in the pelvic region should also be considered. Other signs to look for include fever, discharge or rashes, and changes in behavior like sexual activity or trauma.

It’s also important to ask the patient about any existing medical conditions they might have, as well as the medications they’re currently taking. Certain conditions and medications can actually increase the chance of bleeding or may require the patient to be on blood thinners.

Pain during bowel movements could suggest the presence of anal fissures, while changes in bowel habits and weight loss in older patients might hint at cancer. Hemorrhoids, typically painless bumps in the anal canal, are the most common cause of rectal bleeding in older adults. Symptoms can include bleeding, swelling, discomfort, mucous discharge, itchiness, hygiene difficulties, and a feeling of incomplete bowel evacuation.

• Pain during defecation
• Changes in bowel habits
• Weight loss in older patients
• Presence of hemorrhoids
• Bleeding
• Swelling
• Discomfort
• Mucous discharge
• Itchiness
• Hygiene difficulties
• Feeling of incomplete bowel evacuation

The physical examination for rectal bleeding begins with checking for vital signs. Any signs of low blood pressure, high heart rate, or high respiratory rate could signal a serious condition. A focused examination of the stomach should be conducted in order to check for pain, lumps, bloating, and signs that could hint towards rectal varices. An inspection of the perineum should be carried out with the patient lying on their left side so as to check for blood, hemorrhoids, or any other abnormalities. A rectal examination will also be conducted to check for abnormalities that could be causing the bleeding. While the rectal examination can be uncomfortable and painful, particularly in acute fissure cases, it involves checking for masses and potentially running a fecal occult blood test.

Testing for Rectal Bleeding

If you have symptoms of bleeding, your doctor may order a complete blood count (CBC), which is a type of blood test to help understand the severity of the bleeding and decide on the best treatment plan. Other important tests they may order are the international normalized ratio (INR) and the partial thromboplastin time (PTT). These tests help see if you have a higher chance of bleeding. If you have severe bleeding, you might need a ‘cross-match’ test. This is to ensure that a blood transfusion can be arranged if necessary to keep your hemoglobin level above 7gm/dL. Hemoglobin is the protein in your red blood cells that carries oxygen to your body’s organs and tissues.

If you have engaged in sexual activity through the anus, the doctor may test for sexually transmitted infections, like gonorrhea and chlamydia.

Testing for rectal bleeding usually includes a procedure known as an endoscopy, particularly for patients over 40 years old. This means using a special instrument to look inside your body. The doctor may use an anoscope or procto-sigmoidoscope to check for a source of bleeding near the anus, such as internal hemorrhoids, inflammation of the rectum (proctitis), rectal ulcers, cancer, or varices, which are enlarged veins. A colonoscopy is another type of scope that might be used if there is concern about a health problem in the upper part of the lower gastrointestinal tract (GIT), which includes the colon.

If you have a large amount of bleeding or aren’t stable enough for anesthesia, you might have a CT angiography. This is a type of CT scan that makes detailed images of your blood vessels. If there’s a lot of blood in the gut, it can be hard to figure out the exact place the blood is coming from.

Another option for finding the location of bleeding vessels is a ‘tagged red blood cell scintigraphy’. It might be used for recurring and persistent rectal bleeding when the cause is still unknown. This test involves injecting a small amount of radioactive material into your bloodstream to help visualize and identify where the blood is coming from.

Treatment Options for Rectal Bleeding

Severe, sudden rectal bleeding requires immediate assessment and potentially the start of resuscitation efforts to stabilize the patient’s vital signs. This process may involve intravenous (IV) fluids or medications to increase blood pressure in severe cases. Rectal bleeding severe enough to negatively affect the body’s vital functions is rare, and it’s usually due to serious upper gastrointestinal (GI) bleeding, such as bleeding from swollen veins in the digestive tract (varices), burst ulcers, or an abnormal connection between the aorta (major blood vessel) and the intestine (aortoenteric fistula). These cases may require an upper GI endoscopy, a procedure using a flexible tube with a light and camera to examine the upper GI tract.

If endoscopy is performed, the bleeding can be controlled by certain procedures like burning the area that’s bleeding (cauterization), tying off blood vessels, or injecting the bleeding site with certain substances like epinephrine or sclerosing agents (that cause scarring and hardening of tissues).

Cauterization involves using electrical current to burn away the bleeding site, while sclerosing agents work by irritating tissues and causing blood clotting that can help stop the bleeding during the endoscopy. In cases where the patient undergoes a procedure to visualize blood vessels (angiography), artery blocking (embolization) can be done if the bleeding vessels have been previously identified, as this makes them easily visible in imaging.

If the patient is stable, they can be examined and treated as an outpatient. Here are some common causes of rectal bleeding and their treatments:

Hemorrhoids

Managing hemorrhoids involves a mix of lifestyle changes, outpatient procedures, and surgeries. The conservative or lifestyle approach includes incorporating high fiber foods to reduce the risk of constipation and straining during bowel movements. Stool softeners, fluids, and fiber supplements can help prevent constipation, while sitz baths can reduce the pain and itching of active hemorrhoids. Topical medications are also used to provide temporary relief.

Outpatient treatments primarily include rubber band ligation; this procedure applies a small rubber band at the base of the internal hemorrhoids to reduce their size and blood flow. Other methods include infrared coagulation, which uses heat to treat internal hemorrhoids, and injection sclerotherapy, which involves injecting a scarring agent into the base of the hemorrhoids.

Surgery is reserved for severe cases that do not respond to other treatments, or for patients with additional complications. Surgical hemorrhoid removal, or hemorrhoidectomy, is the most common operation for this condition in the United States. Another option is stapled hemorrhoidectomy, which removes tissue using a circular stapler device.

Anal Fissures

Simple measures such as stool softeners, topical medications that relax the anal muscle, and warm baths may help. If not effective, surgery to loosen the anal muscle (sphincterotomy) may be explored.

Diverticular Bleeding

Diverticular bleeding can cause severe rectal bleeding. This can be controlled by procedures such as injecting a substance to narrow the blood vessels, placing clips, or tying off the blood vessels. In severe cases, a portion of the colon may need to be removed (partial colectomy).

Colon Cancer

Treatment typically involves removing the tumor and the affected section of the colon. This might require comprehensive surgery to remove the tumor, part of the colon, surrounding tissue (mesocolon), and local lymph nodes. Additional treatments like chemotherapy and radiotherapy might also be used, depending on the stage of cancer.

What else can Rectal Bleeding be?

When a person experiences rectal bleeding, doctors need to consider many potential causes. Some could be located further inside the digestive tract, particularly in the colon. The following conditions might be responsible:

• Colon cancer
• Angiodysplasia (abnormal blood vessels in the digestive system)
• Adenomas (benign tumors)
• Inflammatory bowel disease (a group of conditions causing inflammation in the gut)
• Infectious and ischemic colitis (inflammation of the colon due to infection or reduced blood flow)

After ruling out these colon-related conditions, doctors then consider other possible causes:

• Hemorrhoids
• Anal fissures (small tears in the lining of the anus)
• Rectal carcinoma (cancer in the rectum)
• Radiation-induced proctitis (inflammation of the rectum caused by radiation therapy)

What to expect with Rectal Bleeding

The chances of getting better from rectal bleeding depends on what’s causing the bleeding, how severe it is, and the patient’s overall health. In about 95% of cases, rectal bleeding will stop on its own.

Possible Complications When Diagnosed with Rectal Bleeding

External hemorrhoids can sometimes form blood clots, which can lead to severe pain and discomfort. If acute anal fissures, or tears around the anus, are not treated quickly, they could turn into chronic fissures. These may not respond to basic treatments and might need surgical intervention. Cancer in the anal area has the potential to spread to the lymph nodes and other parts of the body if treatment is not started promptly. Ignoring ongoing bleeding can result in anemia with associated symptoms like fatigue, shortness of breath, and chest pain.

Common complications include:

• Blood clots in external hemorrhoids causing pain and discomfort
• Acute anal fissures developing into chronic ones that resist normal treatment
• Cancers spreading to lymph nodes and other organs due to delayed treatment
• Anemia due to untreated bleeding, leading to fatigue, shortness of breath, and chest pain

Preventing Rectal Bleeding

If you notice bleeding from your bottom, particularly if you’re middle-aged or older, it’s really important that you speak to a doctor. This is because the risk of having cancer is higher in these age groups.

Also, if alongside bottom-bleeding, you start vomiting or coughing up blood, you should seek medical help right away. These could be signs of a very serious health problem called an upper gastrointestinal bleed, or it might indicate a bleeding disorder such as thrombocytopenia (a condition where you have a lower-than-normal number of platelets in the blood, leading to excessive bleeding) or anticoagulant toxicity (a dangerous reaction to medications that prevent blood clotting).